Emergency department external cause coding training

Emergency department external cause coding

In this Emergency department external cause coding training of a patient for a injury how the incident has happened i.e nothing but external cause coding is explained clearly.

Head injury chart

Patient name: ABC ,Age :25 Date of service :1/2/2018

MRN number: 123456 Physician name: xyz

Chief complaint: Head injury

Hpi:

Patient is coming with head injury which is painful while walking patient has fallen down from steps hitting the head this happened at home around 3 o Clock in the morning patient denies any other complaint.

PMH:

Personal history : None

Family history : Mother is diabetic

Social history : None

ROS(Review of system):

Constitutional Symptoms: weight : 52

HEENT: Head swelling

Respiratory: Normal

Gastrointestinal: Normal

Genitourinary: Normal

Musculoskeletal: Normal

Neurological: Normal.

Physical Examination:

Constitutional Symptoms: weight : 52

HEENT: contusion of head other than that everything is normal.

Respiratory: Normal

Gastrointestinal: Normal

Genitourinary: Normal

Musculoskeletal: Normal

Neurological: Normal.

Workup done :

Ct head

Findings : swelling is observed in frontal part of head. No intracranial hemorrhage is observered.

Medical decision making:

Patient is coming with head injury physician has Ordered CT head in order to find out any hemorrhage.Negative ct findings except for swelling of head. Injury is cleaned and treated